Covered Entity Details

DSH390270AM GEISINGER WYOMING VALLEY MED CTR (Terminated) - information as of 5/17/2025 10:55:08 PM

Main Details

Name

GEISINGER WYOMING VALLEY MED CTR

Subdivision Name

GEISINGER WYOMING VALLEY MEDICAL - Anesthesia Hospital South Wilkes Barre

Type

Disproportionate Share Hospital

Rural

Yes

340B ID

DSH390270AM

Medicare Provider Number

390270

Outpatient Facility Provider Number

Additional Details

Current Program Status

Terminated

Registration Date

4/3/2018

Participating Start Date

7/1/2018

Participating Approval Date

4/19/2018

Last Recertification Date

9/3/2023

Termination Date
Termination Reason

10/1/2024
Other

Contacts

Authorizing Official

Geisinger Wyoming Valley Medical Center
Ron Beer, Chief Admiistrative Officer
(570) 808-5380

Primary Contact

Geisinger Health
Lola Travelpiece, 340B Program Manager
(570) 214-1035

Addresses

Street Address

25 CHURCH STREET
GWV SWB SURG CENTER
WILKES BARRE, PA 18765-7622

Billing Address

Geisinger Wyoming Valley Medical Center
1000 East Mountain Drive
Wilkes Barre, PA 18711

Comments
Medicaid Billing
Shipping Addresses
Contract Pharmacies
Parent/Child
History

Comments

Comment	Last Updated On
No records to display.

Medicaid Billing

At this site, will the covered entity bill Medicaid fee-for-service for drugs purchased at 340B prices?
Yes

State	Medicaid Number	NPI Number
PA	1007584780022,1007584780026,1007584780016,1007584780023,1007584780019,1007584780017,1007584780014,1007584780021,1007535151333,1007584780002,1007584780008,1007584780009,1007584780012,1007584780027,1007584780030,1007584780033,1007584780029	1205197894,1104292960,1669768214,1912332511,1770953994,1649568403,1235424672,1447538640,1881980803,1437551868,1275620585,1649305129,1669553624,1174822068,1487683348,1316692585,1457959124,1780253336,1942769393,1861791865

Shipping Addresses

Shipping Address 1

Geisinger Wyoming Valley Medical Center
1000 East Mountain Drive
Wilkes Barre, PA 18711

Shipping Address 2

Geisinger South Wilkes Barre
25 Chruch St
Wilkes Barre, PA 18765

Contract Pharmacies

Contract Detail	Pharmacy Name	Address	Address Cont.	City	State	Zip Code	Approval Date	Begin Date	Carve-In Effective Date	Termination Date	Last Updated On
No records to display.

Parent/Child

340B ID	Hierarchy	Entity Type	Name	Sub Name	Address	City	State	340B Status
DSH390270A	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Valley Medical Building / General Surgery Amb Care Fac	1000 East Mountain Blvd	Wilkes Barre	PA	Active
DSH390270AA	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Maternal-Fetal Med Ambulatory Care Clinic	190 WELLES STREET	FORTY FORT	PA	Active
DSH390270AB	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL / Urgent Care South Wilkes Barre Ambulatory Care Clinic	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270AC	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Orthopaedics Ambulatory Care Center	1175 EAST MOUNTAIN DRIVE	WILKES BARRE	PA	Active
DSH390270AD	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Hem Onc Mt Pocono	126 MARKET WAY	MT POCONO	PA	Active
DSH390270AE	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Hem Onc Tunkhannock	809 Hunter Hwy	TUNKHANNOCK	PA	Active
DSH390270AG	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Urology Ambulatory Care Clinic	1000 East Mountain Blvd	Wilkes Barre	PA	Active
DSH390270AH	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Podiatry	1155 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270AJ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Neurophysiology	950 EAST MOUNTAIN DRIVE	WILKES BARRE	PA	Active
DSH390270AK	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Gastroenterology Ambulatory Care Clinic	675 Baltimore Dr	Wilkes Barre	PA	Active
DSH390270AL	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL - Recovery Room South Wilkes Barre	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270AM	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL - Anesthesia Hospital South Wilkes Barre	25 CHURCH STREET	WILKES BARRE	PA	Terminated
DSH390270AN	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL - Operating Rooms South Wilkes Barre	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270AP	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	MRI Tunhannock - MRI Tunhannock	809 Hunter Hwy	Tunkhannock	PA	Active
DSH390270AQ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	General Diagnostic Radiology 1000 E Mountain Dr - General Diagnostic Radiology	1000 East Mountain Blvd	Wilkes Barre	PA	Active
DSH390270AR	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Cat Scanner Tunkhannock - Cat Scanner Tunkhannock	809 Hunter Hwy	Tunkhannock	PA	Active
DSH390270AS	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Tunkhannock Hunter HWY XR Imaging	809 Hunter Hwy	Tunkhannock	PA	Active
DSH390270AT	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	General Diagnostic Radiology South Wilkes Barre - General Diagnostic Radiology South Wilkes Barre	25 Church St	Wilkes Barre	PA	Active
DSH390270AU	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	MT TOP XR Imaging	35 S MOUNTAIN BLVD	MOUNTAIN TOP	PA	Active
DSH390270AV	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	MRI Mt Pocono - MRI Mt Pocono	126 Market Way	Mt Pocono	PA	Active
DSH390270AW	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	XR Imaging Dallas	114 Lt.Michael Cleary Dr	Dallas	PA	Active
DSH390270AX	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	XR Imaging Mt Pocono	126 Market Way	Mt Pocono	PA	Active
DSH390270AY	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Cat Scanner South Wilkes Barre - Cat Scanner South Wilkes Barre	25 Church St	Wilkes Barre	PA	Terminated
DSH390270AZ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Cat Scanner Mt Pocono - Cat Scanner Mt Pocono	126 Market Way	Mt Pocono	PA	Terminated
DSH390270B	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Valley Medical Building / Gastroenterology Amb Care	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270BA	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	XR Imaging Pittston	42 North Main St	Pittston	PA	Active
DSH390270BB	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger South Wilkes Barre - Sleep Disorder Center Lab SWB	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270BC	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL - RESP THERAPY PULMONARY SWB	25 CHURCH STREET	WILKES BARRE	PA	Terminated
DSH390270BD	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL - 5 South Med Surg GSWB- Observation Beds	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270BE	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL - Urology Ambulatory Care Clinic (ACC) South Wilkes Barre (SWB)	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270BF	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL - Emergency Room South Wilkes Barre (SWB)	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270BG	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	ORTHOPEDICS 1155 E MTN BLVD WB - ORTHOPEDICS	1155 E MOUNTAIN BLVD	WILKES BARRE	PA	Terminated
DSH390270BH	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	PULM FUNCTION LAB BALTIMORE DRIVE - PULMONARY MEDICINE	620 BALTIMORE DRIVE	WILKES BARRE	PA	Active
DSH390270BJ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	NEUROLOGY BALTIMORE DR WB - NEUROLOGY	620 BALTIMORE DRIVE	WILKES BARRE	PA	Active
DSH390270BK	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	NEUROPSYCHOLOGY BALTIMORE DR - NEUROPSYCHOLOGY	620 BALTIMORE DRIVE	WILKES BARRE	PA	Active
DSH390270BL	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Cardiac Studies SWB - Cardiac Studies	25 Church St	Wilkes Barre	PA	Active
DSH390270BM	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	CARDIAC REHAB GWV - CARDIOLOGY	675 BALTIMORE DR	WILKES BARRE	PA	Active
DSH390270BN	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Convenient Care Plus GSWV - Convenient Care	25 Church St	Wilkes Barre	PA	Active
DSH390270BP	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - Nephrology	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270BQ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - Phys Therapy Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270BR	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - CT Imaging SWB	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270BS	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - MR Imaging Mt Pocono	126 Market Way	Mount Pocono	PA	Active
DSH390270BT	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - Pulmonary	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270BU	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - Vascular Surgery	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270BV	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - Infectious Disease	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270BW	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - Urology Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270BX	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - Pediatric Neurology	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270BY	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - Occup Therapy Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270BZ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - Lab Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270C	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Valley Medical Building / Neurology Amb Care Fac	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270CA	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - ENT/ Audiology	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270CB	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - GYN Urology SWB	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270CC	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - CT Imaging Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270CD	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - MR Imaging Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270CE	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - US Imaging Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270CF	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - MR Imaging SWB	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270CG	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - Orthopaedics Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270CH	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - XR Imaging Pittston	1201 OAK ST	PITTSTON	PA	Active
DSH390270CJ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - CT Imaging Mt Pocono	126 Market Way	Mount Pocono	PA	Active
DSH390270CK	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Med Ctr - General Surgery	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270CL	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Neuropsychology ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CM	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Dermatology ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CN	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Peds Pulmonary ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CP	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Endocrinology ACC Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CQ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Pediatric Fetal Echo West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CR	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Audiology W Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CS	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Ped Neurology ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CT	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Peds Allergy ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CU	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - MFM Imaging ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CV	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - OR OSCP	1201 OAK ST	PITTSTON	PA	Active
DSH390270CW	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - OB GYN ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CX	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Neurology ACC Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CY	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Urogynecology ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270CZ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Maternal Fetal Med ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270D	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Valley Medical Building / Thoracic Medicine Amb Care	1000 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270DA	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER HEALTHPLEX CENTERPOINT - Ophthalmology ACC Healthplex CenterPoint	1201 OAK ST	PITTSTON	PA	Active
DSH390270DB	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Adult Echocardiography Roosevelt Terrace	50 ROOSEVELT TERRACE	WILKES -BARRE	PA	Active
DSH390270DC	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Clinical Nutrition Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270DD	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Neurosurgery ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270DE	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - MOHS Surgery ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270DF	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley MOB - Vascular Ultrasound MOB	950 East Mountain Blvd	Wilkes Barre	PA	Active
DSH390270DG	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Ultrasound ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270DH	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Otolaryngology ACC West Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270DJ	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Neurophysiology Olive St	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270DK	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE - Gastroenterology ACC West Olive St.	3 W OLIVE ST	SCRANTON	PA	Active
DSH390270DL	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley MOB - GWV MOB XR Imaging	950 East Mountain Blvd	Wilkes Barre	PA	Active
DSH390270DM	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	General Radiology East Mountain Dr - General Radiology	1155 East Mountain Blvd	Wilkes Barre	PA	Active
DSH390270E	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Valley Medical Building / Thoracic Surg Amb	1000 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270F	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Valley Medical Building / Transplant Surgery Ambulatory Care Clinic	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270G	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Geisinger Wyoming Valley Medical Building / Neurosurgery Amb Care Fac	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270H	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Otolaryngology Amb Care Fac	950 East Mountain Drive	Wilkes Barre	PA	Active
DSH390270J	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Plastic Surgery Ambulatory Care Center	675 BALITMORE DR	WILKES BARRE	PA	Active
DSH390270K	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Ophthalmology Amb Care Fac	675 BALTIMORE DR.	WILKES BARRE	PA	Active
DSH390270L	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Dental Med/Oral Surg Ambulatory Care Clinic	675 BALTIMORE DR	WILKES BARRE	PA	Active
DSH390270M	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Rheumatology Amb Care Fac	675 BALTIMORE DR	WILKES BARRE	PA	Active
DSH390270N	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	Gastro Nutrition Ambulatory Care	675 BALTIMORE DR	WILKES BARRE	PA	Active
DSH390270P	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Endocrinology Amb Care Fac	675 BALTIMORE DR	WILKES BARRE	PA	Active
DSH390270Q	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Infectious Disease Ambulatory Care Clinic	675 BALTIMORE DR	WILKES BARRE	PA	Terminated
DSH390270R	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Reproductive Endocrinology	1155 EAST MOUNTAIN BLVD	WILKES-BARRE	PA	Active
DSH390270S	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / UROGYN Ambulatory Care Center	1155 EAST MOUNTAIN DRIVE	WILKES-BARRE	PA	Active
DSH390270T	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / OB Gynecology Amb Care Fac	1155 EAST MOUNTAIN Drive	WILKES-BARRE	PA	Active
DSH390270U	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / General Internal Med Ambulatory Care Center	660 Baltimore Drive	WILKES-BARRE	PA	Active
DSH390270V	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL CE / Dermatolgy AMB Care Fac	1155 EAST MOUNTAIN DRIVE	WILKES-BARRE	PA	Active
DSH390270W	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL / OB Gynecology Ambulatory Care Center South Wilkes Barre	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270X	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL / Pain Mgmt Ambulatory Care Center South Wilkes Barre	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270Y	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL / Adult Psychiatry AMB Clinic Care South Wilkes Barre	25 CHURCH STREET	WILKES BARRE	PA	Active
DSH390270Z	Child	DSH	GEISINGER WYOMING VALLEY MED CTR	GEISINGER WYOMING VALLEY MEDICAL / Peds Urgent Care South Wilkes Barre	25 CHURCH STREET	WILKES BARRE	PA	Active

History

Section	Field	Action	Activity	Value Before	Value After	Timestamp
Details	State	Update		To Be Terminated	Terminated	10/1/2024 12:01 AM
Dates	Last Date That 340B Drugs Purchased	Update	Recertification		8/1/2024 12:00:00 AM	8/28/2024 6:47 AM
Details	State	Update	Recertification	Active	To Be Terminated	8/28/2024 6:47 AM
Terminations	Termination Comments	Update	Recertification		Virtual department that does not see patients	8/28/2024 6:47 AM
Terminations	Termination Date	Update	Recertification		10/1/2024 12:00:00 AM	8/28/2024 6:47 AM
Terminations	Termination Effective Date	Update	Recertification		8/1/2024 12:00:00 AM	8/28/2024 6:47 AM
Terminations	Termination Reason	Update	Recertification		Other	8/28/2024 6:47 AM
Medicaid Billing	NPI: Number	Insert	Group Change Request		1861791865	12/18/2023 12:58 PM
Medicaid Billing	NPI: State	Insert	Group Change Request		PA	12/18/2023 12:58 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007535151275 (PA)		12/15/2023 3:26 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	12/15/2023 3:26 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780029	12/15/2023 3:26 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	12/15/2023 3:26 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1861791865 (PA)		12/15/2023 3:26 PM
Details	Last Recertification Date	Update	Recertification	8/26/2022 10:59:52 AM	9/3/2023 10:30:05 AM	9/3/2023 10:30 AM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007584780018 (PA)		6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007584780015 (PA)		6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007584780020 (PA)		6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007584780013 (PA)		6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Delete	Change Request	1007584780029 (PA)		6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780027	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780030	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780033	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007535151275	6/12/2023 6:08 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1265728810 (PA)		6/12/2023 6:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1093001653 (PA)		6/12/2023 6:08 PM
Medicaid Billing	NPI: Number	Delete	Change Request	1760777106 (PA)		6/12/2023 6:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1316692585	6/12/2023 6:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1457959124	6/12/2023 6:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1780253336	6/12/2023 6:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1942769393	6/12/2023 6:08 PM
Medicaid Billing	NPI: State	Insert	Change Request		PA	6/12/2023 6:08 PM
Contacts	Primary Contact	Update	Profile Change Request	Travelpiece, Lola 340b Analyst Supervisor Geisinger Health 5702141035	Travelpiece, Lola 340B Program Manager Geisinger Health 5702141035	9/26/2022 9:58 AM
Details	Last Recertification Date	Update	Recertification	9/1/2021 9:09:41 AM	8/26/2022 10:59:52 AM	8/26/2022 10:59 AM
Details	Last Recertification Date	Update	Recertification	9/8/2020 10:14:43 AM	9/1/2021 9:09:41 AM	9/1/2021 9:09 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007535151275 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	4201400 (NJ)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780016 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780019 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780025 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780017 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780023 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780026 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780020 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780014 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780021 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780002 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780022 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780022	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780026	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780016	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780018	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780023	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780019	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780017	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780014	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780021	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007535151333	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780015	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780002	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780008	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780009	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780020	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780012	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780013	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Recertification		False	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Insert	Recertification		1007584780029	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780012 (PA)		9/8/2020 10:14 AM
Medicaid Billing	Medicaid: Number	Delete	Recertification	1007584780029 (PA)		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1265728810 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1770953994 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1669553624 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1861791865 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1205197894	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1104292960	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1669768214	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1265728810	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1912332511	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1770953994	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649568403	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1235424672	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1447538640	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1881980803	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1437551868	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1093001653	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1275620585	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1649305129	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1669553624	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1760777106	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1174822068	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1861791865	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Insert	Recertification		1487683348	9/8/2020 10:14 AM
Medicaid Billing	NPI: State	Insert	Recertification		PA	9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1275620585 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1487683348 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1669768214 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649305129 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1649568403 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1437551868 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1205197894 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1235424672 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1912332511 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1760777106 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1447538640 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1881980803 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1174822068 ( )		9/8/2020 10:14 AM
Medicaid Billing	NPI: Number	Delete	Recertification	1104292960 ( )		9/8/2020 10:14 AM
Details	Last Recertification Date	Update	Recertification	8/22/2019 1:14:35 PM	9/8/2020 10:14:43 AM	9/8/2020 10:14 AM
Contacts	Primary Contact	Update	Change Request	Guschel, Timothy 340B Program Director Geisinger Health 5702140155	Travelpiece, Lola 340b Analyst Supervisor Geisinger Health 5702141035	6/2/2020 7:03 AM
Details	Last Recertification Date	Update	Recertification	8/20/2018 8:29:52 AM	8/22/2019 1:14:35 PM	8/22/2019 1:14 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/11/2019 1:55 PM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780022	7/11/2019 1:55 PM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	7/11/2019 1:55 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1265728810	6/30/2019 9:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1770953994	6/30/2019 9:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1669553624	6/30/2019 9:13 PM
Medicaid Billing	NPI: Number	Insert	Change Request		1861791865	6/30/2019 9:13 PM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007535151275	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		4201400	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		NJ	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780016	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780019	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780025	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780017	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780023	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780026	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780020	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780014	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780021	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780002	2/4/2019 10:20 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1669768214	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649305129	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1649568403	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1437551868	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1205197894	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1235424672	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1912332511	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1760777106	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1447538640	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1881980803	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1174822068	2/4/2019 10:20 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1104292960	2/4/2019 10:20 AM
Addresses	Shipping Address	Insert	Change Request		Geisinger South Wilkes Barre 25 Chruch St Wilkes Barre, PA 18765	9/4/2018 10:25 AM
Details	Last Recertification Date	Update	Recertification		8/20/2018 8:29:52 AM	8/20/2018 8:29 AM
Medicaid Billing	Medicaid: Is Primary	Insert	Change Request		False	7/19/2018 8:43 AM
Medicaid Billing	Medicaid: Number	Insert	Change Request		1007584780029	7/19/2018 8:43 AM
Medicaid Billing	Medicaid: State	Insert	Change Request		PA	7/19/2018 8:43 AM
Medicaid Billing	NPI: Number	Insert	Change Request		1487683348	7/19/2018 8:43 AM
Details	State	Update		Approved	Active	7/1/2018 12:00 AM
Contacts	Primary Contact	Update	Profile Change Request	Guschel, Timothy 340B Program Director Geisinger Health System 5702140155	Guschel, Timothy 340B Program Director Geisinger Health 5702140155	6/28/2018 10:45 AM
Contacts	Signed By	Insert	New Registration		Beer, Ron Chief Admiistrative Officer Geisinger Wyoming Valley Medical Center 5708085380	4/19/2018 12:13 PM
Details	340B ID	Update	New Registration		DSH390270AM	4/19/2018 12:13 PM
Details	Entity Subname	Update	New Registration	GEISINGER WYOMING VALLEY MEDICAL	GEISINGER WYOMING VALLEY MEDICAL - Anesthesia Hospital South Wilkes Barre	4/19/2018 12:13 PM
Dates	Participating Approval Date	Update	New Registration		4/19/2018 12:13:02 PM	4/19/2018 12:13 PM
Details	State	Update	New Registration	Pending	Approved	4/19/2018 12:13 PM
Dates	Signed By Date	Update	New Registration		4/3/2018 2:50:12 PM	4/19/2018 12:13 PM
Dates	Start Date	Update	New Registration		7/1/2018 12:00:00 AM	4/19/2018 12:13 PM
Addresses	Main Address	Insert	New Registration		25 CHURCH STREET GWV SWB SURG CENTER WILKES BARRE, PA 18765-7622	4/3/2018 10:43 AM
Addresses	Billing Address	Insert	New Registration		Geisinger Wyoming Valley Medical Center 1000 East Mountain Drive Wilkes Barre, PA 18711	4/3/2018 10:43 AM
Addresses	Shipping Address	Insert	New Registration		Geisinger Wyoming Valley Medical Center 1000 East Mountain Drive Wilkes Barre, PA 18711	4/3/2018 10:43 AM
Medicaid Billing	Medicaid: Is Primary	Insert	New Registration		False	4/3/2018 10:43 AM
Medicaid Billing	Medicaid: Number	Insert	New Registration		1007584780012	4/3/2018 10:43 AM
Medicaid Billing	Medicaid: State	Insert	New Registration		PA	4/3/2018 10:43 AM
Medicaid Billing	NPI: Number	Insert	New Registration		1275620585	4/3/2018 10:43 AM
Contacts	Authorizing Official	Insert	New Registration		Beer, Ron Chief Admiistrative Officer Geisinger Wyoming Valley Medical Center 5708085380	4/3/2018 10:43 AM
Contacts	Primary Contact	Insert	New Registration		Guschel, Timothy 340B Program Director Geisinger Health System 5702140155	4/3/2018 10:43 AM
Details	Last Recertification Date	Insert	New Registration			4/3/2018 10:43 AM
Details	Grant Number	Insert	New Registration			4/3/2018 10:43 AM
Details	340B ID	Insert	New Registration			4/3/2018 10:43 AM
Details	Is Authorizing Official EHB Data	Insert	New Registration			4/3/2018 10:43 AM
Dates	Last Date That 340B Drugs Purchased	Insert	New Registration			4/3/2018 10:43 AM
Details	Medicare Provider Number	Insert	New Registration		390270	4/3/2018 10:43 AM
Details	Entity Name	Insert	New Registration		GEISINGER WYOMING VALLEY MED CTR	4/3/2018 10:43 AM
Details	Program Code	Insert	New Registration		DSH	4/3/2018 10:43 AM
Details	Entity Subname	Insert	New Registration		GEISINGER WYOMING VALLEY MEDICAL	4/3/2018 10:43 AM
Dates	Participating Approval Date	Insert	New Registration			4/3/2018 10:43 AM
Details	State	Insert	New Registration		Pending	4/3/2018 10:43 AM
Dates	Registration Date	Insert	New Registration		4/3/2018 10:43:07 AM	4/3/2018 10:43 AM
Dates	Signed By Date	Insert	New Registration			4/3/2018 10:43 AM
Dates	Start Date	Insert	New Registration			4/3/2018 10:43 AM
Terminations	Termination Comments	Insert	New Registration			4/3/2018 10:43 AM
Terminations	Termination Date	Insert	New Registration			4/3/2018 10:43 AM
Terminations	Termination Effective Date	Insert	New Registration			4/3/2018 10:43 AM
Terminations	Termination Reason	Insert	New Registration			4/3/2018 10:43 AM